Program Memorandum Department of Health andHuman Services (DHHS)

Carriers HEALTH CARE FINANCINGADMINISTRATION (HCFA)

Transmittal B-01-35 Date: APRIL 30, 2001

CHANGE REQUEST 1523

SUBJECT: Health Insurance Portability and Accountability Act of 1996 (HIPAA)Administrative Simplification - Implementation of Version 4010 of theAccredited Standards Committee X12 835 (Payment/Remittance Advice)Transaction Standard Format.

The Secretary of Health and Human Services has established version 4010 of the X12N 835(provider remittance advice), 837 (claim, encounter and coordination of benefit (COB)), 270/271(eligibility query/response), 276/277 (claim status/query response) and 278 (prior authorization)implementation guides as national standards for use by all health care plans in the United States,including carriers and durable medical equipment regional carriers (DMERCs). This fulfills certainrequirements of the administrative simplification provisions of HIPAA. Further information on theHIPAA standards requirements in general may be obtained at http://aspe.hhs.gov/admnsimp. ThisProgram Memorandum (PM) contains the requirements for implementation of the electronicremittance advice (ERA) standard by the standard system maintainers, carriers, and DMERCs.

Version 4010 of the 835 includes some significant changes from earlier versions of Medicare-supported ERA formats. Changes include requirements to electronically void and correct claimhistory when adjusting a claim, rather than simply posting differences in payment; to identify theprimary payer if denying a claim because Medicare is not primary; and to identify any secondarypayer with whom benefits are coordinated. The void/adjustment process will probably impactcontractor workflow for establishment of many account receivables, and may very well involvecontractor staff from areas other than electronic data interchange.

Remittance Advice Standard Requirements

Medicare carriers and DMERCs will continue to use flat files for their internal system programming.The updated X12N 835 version 4010-supportive remittance advice flat file developed in conjunctionwith the Electronic Data Interchange Functional Work Group (EDIFWG) is posted atwww.hcfa.gov/medicare/edi/edi.htm under the document name “B835v4010." Various carriers,DMERC, standard systems, and HCFA representatives have participated in EDIFWG activities.Subsequent adjustments may be issued if necessary to resolve problems detected duringprogramming or testing. The flat file maps each flat file field to the corresponding 835 version 4010data element, and notes if/where each data element was reported in the last of the National StandardFormat (NSF)-based remittance advice flat file (NSF 2.01U).

Attachment 1 is the “Medicare X12N 835 Version 4010 HIPAA Companion Document." Thisitemizes the Medicare requirements for use of specific segments, data elements, and codes in the835. Version 4010 of the 835 implementation guide may be downloaded without charge fromwww.wpc-edi.com/HIPAA, or you may phone 1-800-972-4334 to purchase hard copies.

Remittance Advice Remark Codes

As the initial user of 835 remark codes, HCFA became the defacto maintainer of this code set withASC X12N approval. Since HIPAA applies to virtually all U.S. health care payers, and will resultin much more extensive use of the 835 format, many payers other than Medicare will also begin touse remark codes. Remark code wording must be generic. Language referring to Medicare as thesource of decisions in many remark code messages has been replaced by references to “we" Sincethe remittance advice identifies the issuer (Medicare for a claim processed by a carrier or DMERC),the meaning is the same. Existing message numbers have also stayed the same.

HCFA-Pub. 60B

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Attachment 2 contains the currently approved, generically worded remark code messages. You maybegin to use these messages in both your pre-HIPAA and HIPAA format ERAs and standard paperremittances as soon as programming changes are complete. None of these messages should be newto you, but if you do begin to use any of these messages for the first time, furnish providers advancenotice of the new messages and their meanings prior to initial use. Any remark code may now bereported at either the claim or the line level, i.e., an "MA" code may now be reported in the LQsegment of the 835, and an "M" code in an MOA segment--if the wording of the message fits thesituation being described at that level. "N" codes could always be reported at either the claim or theservice level. All new remark codes will now begin with "N."

Neither a Medicare carrier, DMERC, nor a non-Medicare payer may use a remark code in a version4010 835 transaction that does not appear in attachment 2 or a subsequent HCFA-produced updateto this list. This listing will be updated as needed, and is nationally accessible at www.wpc-edi.comby selecting the Guides, Health Care Code Lists, and Remittance Advice Remark Codes menulistings. Download the remark code message set from this website every quarter to keep abreast ofthe full list of messages approved for use. Attachment 2 and the website also include instructionsto request modifications or additional remark codes. New remark codes introduced to meetMedicare-specific needs will continue to be included in the implementation instruction for theMedicare change that necessitated the new message. Remark codes will not otherwise be publishedin Medicare manuals. Nor will they be maintained on a HCFA website.

Standard Paper Remittance (SPR) and SPR/ERA Patient Account Number Reporting

Only one change is being made to the SPR format. Standard systems, carriers and DMERCs mustcomplete system changes by following HCFA’s normal October quarterly release process to enablereporting of a 20-character patient account number in an X12N 835 version 4010 when a numberthat large is submitted on a version 4010 claim (Attachment 3). The Medicare core system willcontinue to record a maximum of 17 characters for patient account numbers. Patient accountnumbers in excess of 17 characters will be populated from the repository established forcoordination of benefits for both SPRs and ERAs. If a provider requests a SPR or ERA after a 20-character patient account number has been purged from the repository, the SPR/ERA will report thefirst 17-characters only. A similar limitation applies to reporting of provider line item controlnumbers in ERAs (see the note in REF segment repeat 100.A in Attachment 1).

All other data elements included in SPRs and ERAs will be populated from the Medicare coresystem. By as early as October 1, 2001, but no later than October 2002 standard systems mustassure that all data elements that appear in both the SPR and the ERA for the same claim containidentical data. Fields shared by both formats for the same claim may not contain different data. Asin the past, data not available in an ERA may not be reported in a SPR. SPRs will also be limitedto reporting of one secondary payer, even when payment information for a claim is shared with morethan one secondary payer under COB trading partners agreements (see NM1 segment repeat 030.Ein Attachment 1).

Standard systems will also need to modify SPR programming if notified to begin using 11-digitNational Drug Codes (NDC) in lieu of drug HCPCS. HCFA does not plan to replace the drugHCPCS with NDCs before FY 2002. If notified to begin using NDCs in lieu of drug HCPCS, thefirst 5 characters of the NDC must be printed in the 5 space SPR procedure code field and theremaining 6 characters printed in the 6 adjoining spaces normally reserved for HCPCS modifiers.This strategy avoids the need for expansion of the procedure code column and the related increasein the size and cost of most SPRs. Do not take action to replace drug HCPCS with NDCs, however,unless issued a separate HCFA instruction to that effect.

PC-Print

Carriers and DMERCs are no longer required to issue PC-Print software to providers. A survey ofcarriers indicated limited use of the NSF versions of PC-Print previously developed. Providersrealize the most significant benefits of the 835, such as automatic posting of patient records andmaintenance of accounts receivables, when they process the data electronically. When providers usethe 835 as intended by the designers, they should rarely need hard copies of 835 data. Sinceproviders still receive, or can request, SPRs, most carriers and DMERCs do not consider it costeffective, to continue to support PC-Print.

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Carriers and DMERCs who consider there to be a local need for PC-Print software as an 835marketing tool, to retain current 835 customers, or to respond to other demonstrated provider needshave the option to continue to generate PC-Print software. However, carriers and DMERCs whoelect to continue to support PC-Print software, must be able to demonstrate that the benefitsgenerated from the software exceed their costs to support the software. If they elect to continue tosupport PC-Print software, the software must operate on Windows 95, 98, 2000, and NT platforms,be distributed to providers free or at cost, comply with the SPR format for reporting of remittanceadvice data, and be available for distribution to providers by January 2, 2002.

Manualization of this Information

The Medicare Carriers Manual sections dealing with the 835 transaction will be updated to includechanges detailed in this and other HIPAA PMs. HCFA plans to combine and manualize all of theHIPAA transactions information at the same time, following release of individual PMs for thevarious transactions. The DMERC contracts are also being updated to correspond to these changes.

Testing and Implementation

Standard system programming must be completed and the system changes and relateddocumentation distributed to the processing centers according to the normal October release process,i.e., the release must be sent to the carrier/DMERC beta testers in August, and carriers and DMERCsmust begin their testing of this change request by September. As per normal practice, HCFA willnot issue test files to the carriers or DMERCs. Each carrier and DMERC is responsible for thedevelopment of appropriate test files, either alone or in conjunction with other carriers and/orDMERCs.

Carriers and DMERCs must complete translator mapping for the 835 by September 30, 2001.Carriers and DMERCs must complete local system programming and internal testing to enablesuccessful interface with their standard system for accurate generation of version 4010 of the 835and the SPR from the 4010 flat file by November 30, 2001. Carriers and DMERCs must conductlimited provider beta testing of the 835 version 4010 with a small number of providers and/oroutside clearinghouses involving a small number of claim batches during December 2001.

By January 2, 2002, carriers and DMERCs must be able to conduct system compatibility testing onversion 4010 of the 835 with any Medicare provider or clearinghouse that applies for testing, andto issue 835 version 4010 transactions in production mode. Carriers and DMERCs may notdiscourage any provider, billing agent or clearinghouse from requesting 835 version 4010 testing.If either a provider, billing agent, clearinghouse, or a carrier or DMERC has any doubt about areceiver’s acceptance and ability to use 835 version 4010 transmissions, the carrier or DMERC mustencourage that receiver to test use of version 4010 of the 835 prior to full use in production.

Standard systems must support testing of providers and clearinghouses in 835 version 4010 at thesame time production data is issued to the same providers and clearinghouses in a pre-4010 835 oran NSF version. Standard systems that do not already possess such parallel testing and productioncapability must be modified by December 1, 2001, to enable carriers and DMERCs to test version4010 of the 835. More detail on specific testing requirements for providers, billing services, andclearinghouses will be issued in a separate PM.

Standard systems must also include program logic to enable carriers and DMERCs to identifysituations where the flat file financial data may not have created a balanced 835 as specified insection 2.2.1 of the 835 version 4010 implementation guide. The logic must operate at the datacenter to generate an “out of balance” report that carriers and DMERCs can use to diagnose standardsystem errors for preparation of standard system correction requests. “Out-of-Balance” 835s shouldbe rare exceptions, and not something to be expected, but this report would enable identification ofbalancing errors prior to transmission of data to providers. Carriers and DMERCs should notsuspend transmission of 835 transactions pending correction of any identified balancing problemsby their standard system, but depending on the nature of any identified problems, should alertproviders regarding temporary problems they could experience pending necessary system correction.

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Carriers and DMERCs must educate their providers on the differences between their current ERAsand the 835 version 4010 to avoid provider misinterpretation of reporting variations between theversions/formats. The version 4010 correction/reversal process may be particularly confusing tosome providers, and in cases where different balancing logic is used, as in version 3030 versusversion 4010, providers will need to be made aware of the changes they will encounter.

Provider and Clearinghouse Outreach

By November 30, 2001, carriers and DMERCs must notify their providers, third party providerbilling services, provider clearinghouses, and vendors of/that:

? Each provider that has elected to receive an ERA must accept version 4010 of the 835, orcontract with a clearinghouse to translate data from the 835 version 4010 standard on theirbehalf;

? A provider, provider billing service, trading partner, vendor or clearinghouse that elects touse a clearinghouse for translation services is liable for those costs;

? Whether PC-Print software will be issued for use with 835 version 4010, and if issued, whenit will be available (no later than January 2, 2002) and how it may be obtained;

? The version 4010 835implementation guide can be downloaded without charge fromwww.wpc-edi.com/HIPAA.

? Providers, agents, and clearinghouses who prefer advance testing to assure systemcompatibility of version 4010 of the 835 must schedule testing with their carrier or DMERCas soon as possible to obtain a testing appointment prior to October 2002. Appointment slotswill be assigned on a first come basis. Each carrier and DMERC should come up with it's owntesting schedule, and inform the providers, agents and clearinghouses about the specificdeadline to request testing with that specific carrier or DMERC. Carriers and DMERCs willnot be able to guarantee completion of testing by the end of September 2002 for any entitiesthat delay requesting a testing appointment until late in the transition period. Unless a providerrequests discontinuation of receipt of ERAs, current 835 and NSF remittance recipients willautomatically be sent production 835 version 4010 transactions in October 2002;

? As result of the large number of providers, agents, clearinghouses, and trading partners thatcould request to be tested and the number of HIPAA standard transactions, it may not befeasible to test each entity during the last quarter of the transition process;

• Providers who request a copy of a previously issued ERA after: 1) a patient account numberin excess of 17-characters has been purged from Medicare records will be sent only the first 17-characters of that patient account number; and 2) provider line item control numbers have beenpurged from Medicare records will not receive those control numbers in the ERA copy. Thepatient account number limitation applies to SPRs also. Line item control numbers are neverreported in SPRs;

? There is no Medicare charge for this system testing; and

? Although Medicare will furnish providers with basic information on the HIPAA standardtransaction requirements to enable providers to make educated and timely decisions to plan fortheir transition to the HIPAA standards, Medicare will not furnish in-depth training on the useand interpretation of the standards implementation guides. Providers who feel they have a needto obtain such in-depth training for their staff are expected to obtain training of that nature fromcommercial vendors, their clearinghouse, or through standards development organizations.

Carriers and DMERCs must be pro-active to assure that:

? Providers, agents, and clearinghouses are furnished adequate information for them tounderstand the impact of the HIPAA Administrative Simplification requirements, asimplemented by Medicare, on their operations. Carriers and DMERCs must furnish appropriate

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information in regularly scheduled provider bulletins/newsletters, in other provider educationalpublications, and during their regularly scheduled provider educational seminars to enable

those individuals and entities to make educated and timely decisions to plan their reaction tothe HIPAA standards as implemented by Medicare; and

? A reasonable number of tests are conducted monthly throughout the transition period toenable Medicare providers, agents, and clearinghouses who request testing to complete testingbefore HCFA must discontinue support of non-HIPAA compliant electronic transactions.

Cost Issues

The Budget and Performance Requirements specify that carriers include one 835 upgrade per yearin their line 1 routine maintenance costs. However, carriers are entitled to non-routine cost incurredfor: translator upgrade if required to accommodate a higher volume of X12N transactions underHIPAA, translator mapping to the new X12N-based flat files, provider education on 835 version4010 requirements, testing of SPR accuracy when generated with the 835 version 4010 flat file,provider beta testing of the 835 version 4010 with selected partners, optional PC-Print softwaredesign when cost effective, and system compatibility testing of providers, their agents, andclearinghouses at their request prior to issuance of the 835 version 4010 in production mode.Carriers should submit Supplemental Budget Requests for reasonable supplemental costs incurredto comply with these non-routine 835 requirements in FY 2001 and FY 2002.

DMERCs were not previously required to implement any ASC X12N standards. DMERCs areentitled to reasonable costs for implementation, testing, and transition to these ASC X12N standards,and should submit SBRs in FY 2001 and FY 2002 for the reasonable and allowable costs they incurto use version 4010 of the 835 transaction as described in this PM.

HIPAA established requirements binding on all health care payers, not only on Medicare. HIPAAdid not fund national implementation of its Administrative Simplification standards requirementsby all health payers. As with other system and program changes that impact a Medicare contractor=sparent company’s private/commercial lines of business as well as their Medicare processingactivities, direct and indirect costs related to such changes must be proportionately shared by theimpacted lines and cost centers, and not charged to Medicare in total. Programming, transition, andoperational costs related to a corporate clearinghouse operated by a Medicare contractor’s parentcompany, or any other profit or non-profit line of business of the parent company not required tosupport Medicare processing under the terms of their Medicare contract, may not be charged in totalor in part to the Medicare program.

The effective date and implementation date for this PM is October 1, 2001.

See the section of the instruction labeled "Cost Issues" for implementation cost information.For DMERCs only: HCFA is preparing a contract modification. Do not begin work on thisPM until the modification is executed.

This PM may be discarded after January 1, 2003.

Contact person for the remittance advice information is Kathleen Simmons, (410) 786-6157.

3 Attachments

Attachment 1

MEDICARE X12N 835 VERSION 4010

HIPAA COMPANION DOCUMENT

INTRODUCTION

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires that Medicare,and all other health insurance payers in the United States, comply with the electronic datainterchange standards for health care as established by the Secretary of Health and Human Services.The X12N 835 version 4010 implementation guide has been established as the standard forcompliance for remittance advice transactions. The implementation guide for that format isavailable electronically at www.wpc-edi.com/HIPAA.

Although that implementation guide contains requirements for use of specific segments and dataelements within the segments, the guide was written for use by all health benefit payers, and notspecifically for Medicare. This document has been prepared as a Medicare-specific companiondocument to that implementation guide and the flat file to clarify when conditional data elementsand segments must be used for Medicare reporting, and identify those codes and data elements thatnever apply to Medicare and which may not be used in Medicare remittance advice transactions.This companion document supplements, but does not contradict any requirements in the 835 version4010 implementation guide.

Table 1 - Header Data

Segment/ 835 and Medicare Requirements/NotesData Elements

ST Required.ST01 Required. Always enter “835.”ST02 Required.

BPR Required.BPR01 Required. Codes U and X do not apply to Medicare.BPR02 Required.BPR03 Required. Code D does not apply to Medicare.BPR04 Required. Codes BOP and FWT do not apply to Medicare.BPR05 Situational, but required for Medicare if ACH is entered in BPR04.BPR06 Situational, but required for Medicare if ACH in BPR04. Code 04 does not apply to

Medicare.BPR07 Situational, but required for Medicare if ACH in BPR04.BPR08 Situational, but required for Medicare if ACH in BPR04.BPR09 Situational, but required for Medicare if ACH in BPR04.BPR10 Situational, but required for Medicare if ACH in BPR04.BPR11 Situational, but does not apply to Medicare and should not be reported.BPR12 Situational, but required for Medicare if ACH in BPR04. Code 04 does not apply to

Medicare.BPR13 Situational, but required for Medicare if ACH in BPR04.BPR14 Situational, but required for Medicare if ACH in BPR04.BPR15 Situational, but required if ACH in BPR04.BPR16 Required.BPR17-21 Not used.

TRN Required.TRN01 Required.TRN02 Required.TRN03 Required.TRN04 Situational, but does not apply to Medicare.

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CUR Situational, but does not apply to Medicare.

REF (060.A) Situational, but required for Medicare if the 835 is being sent to any entity otherthan the provider.

REF01 Required.REF02 Required.REF03-04 Not used.

REF (060.B) Situational, but required for Medicare to identify a local version number for theimplementation. Sometimes a local version number is needed to identify a post-implementation modification in programming, such as to correct a programmingerror. The local version number could be needed to answer a provider inquiryrelated to the programming modification.

REF01 Required.REF02 Required. The version number is assigned locally.REF03-04 Not used.

DTM (070) Situational, but required for Medicare if the date of the 835 is different than thecutoff date for the adjudication action that generated the 835.

DTM01 Required. DTM02 Required.DTM03-06 Not used.

N1 (080.A) Required for payer identification.N101 Required.N102 Situational, but required for Medicare.N103 Situational. Always enter “XV” in this loop when the PlanID is effective,

but not used prior to that date.N104 Situational, but required once the PlanID is effective.N105-106 Not used.

N3 (100) Required for payer identification. N301 Required.N302 Situational, but required by Medicare if there is more than 1 address line for

the payer, such as for a suite number.

N4 (110) Required for payer identification.N401 Required.N402 Required.N403 Required.N404-406 Not used.

REF (120.A) Situational. Required for Medicare prior to the effective date of the Plan ID. Afterthat date, a Medicare payer may use at its option in addition to the Plan ID in the060 REF.

REF01 Required. Only 2U applies to Medicare.REF02 Required.REF03-04 Not used.

PER (130) Situational. Recommended for use for Medicare, but reporting of contactinformation in an 835 is at the option of individual Medicarecontractors.

PER01 Required.PER02 Situational. Optional for Medicare but recommended if this segment is used.PER03 Situational, but required for Medicare if this segment is used.PER04 Situational, but required for Medicare if there is an entry in PER03.PER05 Situational. May be used at the option of a Medicare contractor to report a second

contact.

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PER06 Situational, but required if there is an entry in PER05.PER07 Situational, but required for Medicare if segment is used and it is necessary

to report a telephone extension number.PER08-09 Not used.

N1 (080.B) Required to identify the payee.N101 Required.N102 Situational, but required for Medicare prior to the effective date of the NPI.N103 Required. Always enter “FI” until the NPI is effective. After that date, always

enter “XX.”N104 Required.N105-106 Not used.

N3 (080) Situational, but required for Medicare.N301 Required.N302 Situational, but required if there is a second payee address line.

N4 (100.B) Situational, but required for Medicare.N401 Required.N402 RequiredN403 Required.N404 Situational. Only required if the address is other than the U. S.N405 Not used.N406 Not used.

REF (120.B) Situational, but required for Medicare.REF01 Required. Always enter “TJ” in this loop when the NPI is effective. Prior to that

date, use 1C (Medicare provider number) or 1G (UPIN) for Medicare. 0B, 1A,1B,1D, 1E, 1F, 1H, D3, G2, N5 and PQ do not apply to Medicare.

REF02 Required.REF03-04 Not used.

Table 2 - Detail Data

LX Situational, but required for Medicare.LX01 Required.

TS3 Situational. Not used by Medicare carriers, only by intermediaries.

TS2 Situational. Not used by Medicare carriers, only by intermediaries.

CLP Required.CLP01 Required.CLP02 Required. Codes 25 and 27 do not apply to Medicare and are not in the flat file.CLP03 Required.CLP04 Required.CLP05 Situational, but required for Medicare if there is any patient financial

responsibility for amounts not paid by Medicare.CLP06 Required. Carriers always enter “MB.” None of the other 835 codes apply to

Medicare.CLP07 Situational, but required for Medicare.CLP08 Situational, but required for Medicare.CLP09 Situational, but does not apply to Medicare carriers.CLP10 Not used.CLP11 Situational, but does not apply to carriers.CLP12 Situational, but does not apply to carriers.CLP13 Situational, but does not apply to carriers.

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CAS (claim) Situational, but does not apply to carriers. Adjustments for Medicare carriersshould always be reported at the line level Unlike prior 835 versions, version4010 does not require entry of an OA 93 message in a claim level CAS whenthere are no claim level adjustments.

NM1 (030.A) Required to report patient-related information.NM101 Required.NM102 Required.NM103 Required.NM104 Required.NM105 Situational, but required for Medicare when a middle name or initial is available

for the patient.NM106 Not used.NM107 Situational, but will not be used for Medicare.NM108 Situational, but required for Medicare. Always enter “HN” for Medicare, until

notified that the HIPAA Individual Identifier is effective, at which point enter“II” in this data element. None of the other qualifiers apply to Medicare.

NM109 Situational, but required for Medicare if reported on the incoming claim.NM110-111 Not used.

NM1 (030.B) Situational, but the loop is intended for information on an insured when differentthan the patient. This situation does not apply in Medicare. Not used.

NM1 (030.C) Situational, but is required for Medicare when the patient’s name, as received onthe claim, has been corrected.

NM101 Required. For Medicare purposes, the insured is the patient.NM102 Required. Code 2 does not apply to Medicare.NM103 Situational, but required for Medicare if the last name has been corrected.NM104 Situational, but required for Medicare if the first name has been corrected.NM105 Situational, and optional for Medicare carrier to report a corrected middle name

or initial.NM106 Not used.NM107 Situational, but not used for Medicare.NM108 Situational, but required for Medicare if the ID # has been corrected.NM109 Situational, but required for Medicare if the ID # as been corrected.NM110-111 Not used.

NM1 (030.D) Situational, but required for Medicare if the rendering provider is other than thepayee.

NM101 Required.NM102 Required. Code 2 does not apply to Medicare.NM103 Situational, but do not report for Medicare. (Medicare reports only the number,

not the name of the rendering provider.)NM104 Situational, but do not report for Medicare. (Medicare reports only the number,

not the name of the rendering provider.)NM105 Situational, but do not report for Medicare. (Medicare reports only the number,

not the name of the rendering provider.)NM106 Not used.NM107 Situational, but do not report for Medicare. (Medicare reports only the number,

not the name of the rendering provider.)NM108 Required. Until the NPI is effective, always enter “UP ” for Medicare. When the

NPI is effective, always enter “XX.” BD, BS, FI, MC, PC, and SL do not applyto Medicare.

NM109 Required.NM110-111 Not used.

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NM1 (030.E) Situational, but required for Medicare if claim data is being transferred to anotherpayer under a coordination of benefits (COB) agreement with that payer. Note:Although Medicare may send claim and payment information to multiplesecondary payers, the 835 does not permit identification of more than one ofthose secondary payers. When COB transmissions are sent to more than onesecondary payer for the same claim, enter remark code N89 (see Attachment 2)in a MOA segment remark code data element.

NM101 Required.NM102 Required.NM103 Required.NM104-107 Not used. NM108 Required. Until the PlanID is effective, always enter “PI” for Medicare; when

effective, enter “XV.” AD, FI, NI, and PP do not apply to Medicare.NM109 Required. NM110-111 Not used.

NM1 (030.F) Situational. Required for Medicare when a claim is denied or rejected due to theneed for processing by a primary payer. That primary payer should be identifiedin the remittance advice.

NM101 Required.NM102 Required.NM103 Required.NM104-107 Not used.NM108 Required. Until the PlanID is effective, always enter “PI” for Medicare in this

loop. When effective, always enter “XV” for Medicare. AD, FI, NI, and PP donot apply to Medicare.

NM109 Required. Enter the PlanID when effective. Prior to that date, zero-fill.NM110-111 Not used.

MIA Situational, but does not apply to Medicare carriers.

MOA Situational, but required for Medicare whenever any claim level remark codeapplies, such as an appeal rights remark code or when there is more than oneCOB payer.

MOA01 Situational, but does not apply to Medicare carriers.MOA02 Situational, but does not apply to Medicare carriers.MOA03 Situational, but required for Medicare whenever at least one claim level remark

code applies, such as for an appeal remark code.MOA04 Situational , but required for Medicare if more than one claim level remark code

applies.MOA05 Situational, but required for Medicare if a third claim level remark code applies.MOA06 Situational, but required for Medicare if a fourth claim level remark code applies.MOA07 Situational, but required for Medicare if a fifth claim level remark code applies.MOA08 Situational, but does not apply to Medicare carriers.MOA09 Situational, but does not apply to Medicare carriers.

REF (040.A) Situationa l, but does not apply to Medicare carriers.

REF (040.B) Situational, but does not apply to Medicare. Carriers identify rendering providers,if different than billing providers, at the service level.

DTM (050) Situational, but required for Medicare.DTM01 Required. Always enter “050" for Medicare. This data element would only be

used to report the date of receipt of the claim. Medicare carriers must report thestart and end dates of care at the service level, and expiration of coverageinformation (036) does not apply to Medicare.

DTM02 Required.DTM03-06 Not used.

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PER Situational, Medicare contractors may report contact information at their option,either in table 1, or table 2, but it should not be necessary to report contactinformation in both tables.

PER01 Required.PER02 Situational, and optional for use by a Medicare carrier. If furnished, contact data

must be supplied by the carrier rather than the standard system.PER03 Situational, but required for Medicare if the segment is used. Contact data must

be furnished by the carrier.PER04 Situational, but required for Medicare if this segment is used. Carrier must

furnish the data.PER05 Situational, and optional for use by a Medicare carrier if the carrier would like

to report additional contact information. If used, the data must be furnished bythe carrier.

PER06 Situational, but required for Medicare if an entry in PER05. Data must befurnished by the carrier.

PER07 Situational, and optional for a carrier to use to report the extension number of anyphone number reported in PER04 or 06. Data must be furnished by the carrier.

PER08 Situational, and optional for a carrier to use to report the extension number of anyphone number reported in PER04 or 06. Data must be furnished by the carrier.

PER09 Not used.

AMT (062) Situational, but required for Medicare if the claim reported the patient made anypayment for the claim.

AMT01 Required. Only F5 and I apply to Medicare carriers. No other codes for this dataelement apply to Medicare.

AMT02 Required.AMT03 Not used.

QTY Situational, but does not apply to Medicare carriers.

SVC Situational, but required for Medicare carriers. Note: The HCPCS, modifiers, andwhen applicable, NDC code reported on a claim for a service must be reportedon the 835 for that service, including in situations where a service is beingadjusted for submission of an invalid procedure code or modifier. This situationis considered an exception to the HIPAA requirement that standard transactionsbe limited to reporting of va lid medical codes.

SVC01-1 Required. Only codes HC and N4 apply to Medicare carriers. A separate loopneed for each service reported.

SVC01-2 Required.SVC01-3 Situational, but required for Medicare if HC applies and at least one modifier was

reported on the claim for the service.SVC01-4 Situational, but required for Medicare if HC applies and a second modifier was

reported on the claim for the service.SVC01-5 Situational, but required for Medicare if HC applies and a third modifier was

reported on the claim for the service.SVC01-6 Situational, but required for Medicare if HC applies and a fourth modifier was

reported on the claim for the service.SVC01-7 Situational, but text language may not be reported for Medicare on a remittance

advice.SVC02 Required.SVC03 Required.SVC04 Situational, but does not apply to carriers.SVC05 Situational, but required for carriers.SVC06-1 Situational, but required if the procedure or drug code has been changed during

adjudication. Only HC and N4 apply to Medicare carriers.SVC06-2 Required.SVC06-3--7 Situational, but required for Medicare if modifiers are changed.

7

SVC07 Situational, but required for Medicare if the paid units of service is different thanthe billed units of service.

DTM (080) Situational, but required for Medicare.DTM01 Required.DTM02 Required.DTM03-06 Not used.

CAS (svc) Situational , but required for Medicare whenever the amount paid for a servicedoes not equal the amount billed. Medicare carriers are required to separatelyreport every adjustment made to a service.

CAS01 Required. PI does not apply to Medicare. Necessary to use separate loops ifmore than 1 group code applies, or if there are more than 6 procedure codes pergroup.

CAS02 Required.CAS03 Required.CAS04 Situational, but not used for Medicare.CAS05 Situational, but required for Medicare if there is a second service level

adjustment. CAS06 Situational, but required for Medicare if there is a second service level

adjustment.CAS07 Situational, but not used for Medicare.CAS08 Situational, but required for Medicare if there is a third service level adjustment.CAS09 Situational, but required for Medicare if there is a third service level adjustment.CAS10 Situational, but not used for Medicare.CAS11 Situational, but required for Medicare if there is a fourth service level adjustment.CAS12 Situational, but required for Medicare if there is a fourth service level adjustment.CAS13 Situational, but not used for Medicare.CAS14 Situational, but required for Medicare if there is a fifth service level adjustment.CAS15 Situational, but required for Medicare if there is a fifth service level adjustment.CAS16 Situational, but not used for Medicare.CAS17 Situational, but required for Medicare if there is a sixth service level adjustment.CAS18 Situational, but required for Medicare if there is a sixth service level adjustment.CAS19 Situational, but not used for Medicare.

REF (100.A) Situational, but required for Medicare.REF01 Required. Only LU and 6R apply to Medicare. Two loops must be used if both

LU and 6R apply.REF02 Required. Note: The provider line item control number (6R) is not used by and

will not be retained by the Medicare core system. As with a 20-digit patientaccount number, use the COB data repository to populate REF02 for 6R. Do notreport 6R in REF01 of a reissued ERA if there is no line item control number inthe repository.

REF03-04 Not used.

REF (100.B) Situational, but required for Medicare if the rendering provider for the service isother than the payee.

REF01 Required. Prior to the NPI effective date, always enter “1C” (the flat file doesnot differentiate between a UPIN and any other Medicare provider number) inthis loop. After the NPI is effective, enter “HPI.” The other codes do not applyto Medicare.

REF02 Required.REF03-04 Not used.

AMT (110) Situational, but required for Medicare carriers if any of the qualifiers apply.AMT01 Required. Only KH and B6 apply to Medicare. Two loops must be used for

Medicare if both apply.AMT02 Required.

8

AMT03 Not used.

QTY Situational, but does not currently apply to Medicare carriers.

LQ Situational, but required for Medicare whenever any service level remark codesapply.

LQ01 Required. Always enter “HE” for Medicare.LQ02 Required.

Table 3 - Summary

PLB Situational, but required for Medicare whenever there have been any provider-level adjustments.

PLB01 Required.PLB02 Required. Carriers must furnish this from their provider file, or use a default

value of 12/31 of the current year.PLB03-1 Required. Only codes CS, AP, FB, LE, L6, 50, SL, WO, B2, J1, and IR apply

to Medicare carriers.PLB03-2 Situational, but required for Medicare. Positions 1-2=00 Positions 3-19=the

Financial Control Number, Positions 20-30=the HIC number. NOTE: The notein the implementation guide is misphrased. Medicare carriers and DMERCs mustreport this information in these positions in this data element.

PLB04 Required.PLB05-1 Situational data element, but required if there is a second provider level

adjustment.PLB05-2 Situational, but required if there is a second provider level adjustment.PLB06 Situational, but required if there is a second provider level adjustment.PLB07-1 Situational, but required if there is a third provider level adjustment.PLB07-2 Situational, but required if there is a third provider level adjustment.PLB08 Situational, but required if there is a third provider level adjustment.PLB09-1 Situational, but required if there is a fourth provider level adjustment.PLB09-2 Situational, but required if there is a fourth provider level adjustment.PLB10 Situational, but required if there is a fourth provider level adjustment.PLB11-1 Situational, but required if there is a fifth provider level adjustment.PLB11-2 Situational, but required if there is a fifth provider level adjustment.PLB12 Situational, but required if there is a fifth provider level adjus tment.PLB13-1 Situational, but required if there is a sixth provider level adjustment. Two loops

must be used for Medicare if both apply.PLB13-2 Situational, but required if there is a sixth provider level adjustment.PLB14 Situational, but required if there is a sixth provider level adjustment.

SE Required.SE01 Required. The transaction segment count is computed by the carrier system.SE02 Required.

Attachment 2

REMITTANCE ADVICE REMARK CODES (Updated 4/12/2001){PRIVATE }

{PRIVATE }General{tc \l 1 "General"}

Remark codes are used in a remittance advice to relay informational messages that cannotbe expressed with a claim adjustment reason code. Remark codes are maintained by HCFA,but may be used by any health care payer when they apply. Medicare contractors may usetheir discretion to determine when certain remark codes apply to a payment decision, but aMedicare contractor must report any remark codes that do apply, subject to capacity limitsin the standard.

Most remark codes were initially separated into service level and claim level categories.Some of the same messages were included in both categories. To simplify remark code use,these categories have been eliminated. Any remark code may now be reported at the serviceor the claim level, as applicable, in any electronic or paper remittance advice version. Toeliminate duplication, the following remark code messages have been made inactive andshould no longer be used effective with implementation of version 4010 of the X12 835:M34 (duplicates MA120), M72 (duplicates MA52), MA05 (information included in MA30,or MA40 or MA43), N41 (duplicates reason code 39), and N44 (duplicates reason code 137).

Rather than renumber existing M (prior service level) and MA (prior claim level) codes, andpossibly confuse providers, “old" code numbers have been retained. All new post-consolidation remark codes, however, will begin with an N. The "N" is used to quicklydifferentiate remark codes from claim adjustment reason codes. Remark codes that applyat the service level must be reported in the X12 835 LQ segment. Remark codes that applyto an entire claim must be reported in the X12 835 MIA (inpatient) or MOA (non-inpatient)segment, as applicable.

Due to the growing number of remark codes, the codes have been classified according tosubject matter to make it easier to locate particular remark codes. Some codes are listedunder multiple classes. Class does not have any bearing on remark code identifiers,however. No intelligence is built into the number issued a remark code.

{PRIVATE }Remark Code Changes/Additions {tc \l 1 "Remark CodeChanges/Additions"}

The following M codes contain changes or are new since release of the October 1998 versionof this list: M51, M109, M110, M116, M118, M120-M144. Codes M122-137 are substitutesfor the D series reason codes, which will be inactive for use in X12 835 transactionseffective with version 4010. Effective with version 4010, the information formerly in D1-15will be conveyed with reason code 16 and the appropriate remark code. The information inD98 will be conveyed with reason code 96 and remark code M137.

The following MA codes have changed or been added since release of the October 1998version of this list: MA06, MA44, MA52, MA118, MA119, MA125, MA130-MA134.Codes MA131 and 132 are substitutes for the D series reason codes D97 and D99 which willbe inactive for use in X12 835 transactions effective with version 4010. Effective withversion 4010, the information formerly in D97 and D99 will be conveyed with reason code96 and the applicable remark code.

2

The following N codes have been changed or added since October 1998: N3,N10, N16 ff.

{PRIVATE }Remark Code Classifications{tc \l 1 "Remark Code Classifications"}Appeal Remarks: M25, M26, M27, M60, MA01, MA02, MA03, MA28, MA44, MA46,MA62, MA91, MA113, MA130, N1, N11, N83

Assignment Remarks: M40, MA09, MA28, MA72, N71

Coverage Remarks: M13, M14, M28, M37, M41, M55, M61, M63, M65, M71, M73, M74,M80, M82, M83, M86, M89, M90, M100, M101, M107, M111, M115, M116, M121, M134,M138, M139, M140, MA14, MA20, MA84, MA103, MA109, MA123, N30, N43, N86, N87

Enrollment Remarks : M138, MA25, MA47, MA54, MA55, MA56, MA57, MA73, MA96,MA97, MA98, N6, N12, N30, N52

Equipment/Orthotic/Prosthetic Remarks: M3, M4, M5, M6, M7, M9, M10, M11, M36,M93, M94, M98, M102, M103, M104, M105, M106, M112, M113, M114, M115, M116,M124, M125, MA50, MA128

Home Care Remarks : M18, M21, M92, M95, M135, M141, MA49, MA76, MA116, N69,N70, N88

Justification for Services Remarks: M25, M26, M42, M62, M69,MA20, MA54,N41,N72

Liability Remarks: M17, M25, M26, M27, M38, M39, M41, M48, MA11, MA13, MA47,MA56, MA59, MA72, MA74, MA77, MA78, MA101, N12, N23, N44, N58, N71

Medical Test Remarks: M1, M8, M12, M19, M30, M31, M66, M71, M73, M75, M88, M91,M96, M108, M111, M126, M129, M133, M142, MA51, MA110, MA111, MA116, MA120,MA121, MA129, N40,N86

Missing/Invalid Information Remarks: M12, M19, M20, M21, M22, M23, M24, M29, M30,M31, M33, M34, M35, M42, M44, M45, M46, M47, M49, M50, M51, M52, M53, M54,M56, M57, M58, M59, M60, M62, M64, M65, M67, M68, M69, M72, M73, M76, M77,M78, M79, M81, M84, M96, M98, M99, M101, M108, M110, M119, M120, M122, M123,M124, M125, M126, M127, M128, M129, M130, M131, M132, M133, M135, M136, M141,M142, M143, MA04, MA05, MA06, MA19, MA21, MA27, MA29, MA30, MA31, MA32,MA33, MA34, MA35, MA36, MA37, MA38, MA39, MA40, MA41, MA42, MA43, MA48,MA49, MA50, MA51, MA52, MA53, MA54, MA58, MA60, MA61, MA63, MA64, MA65,MA66, MA68, MA69, MA70, MA71, MA75, MA76, MA81, MA82, MA83, MA85, MA86,MA87, MA88, MA89, MA90, MA92, MA94, MA95, MA96, MA97,MA98, MA99, MA100,MA102, MA104, MA105, MA107, MA108, MA110, MA111, MA112, MA113, MA114,MA115, MA116, MA120, MA121, MA122, MA128, MA129, MA130, MA134, N3, N4,N5, N8, N21, N24, N26,N27, N28, N29, N31, N33, N34, N37, N38, N39, N40, N42, N46,N49, N50, N51, N53,N54, N56, N57, N60, N64, N65, N66,N75,N76,N77,N78,N80,N81

3

Overpayment Remarks: MA10, MA11, MA59, MA72, MA77, MA78

Payment Basis: M32, M69, M71, M74, M75, M109, M114, MA93, MA101, MA103,MA106, MA109, N2, N6, N9, N12, N13, N14, N16, N18, N45,N67, N68,N69,N84,N85.

Place of Service Remarks: M77, M97, M134, MA24, MA25, MA105, MA114, MA115,MA123, MA134, N38, N47,N79

Responsible Provider: M40, M43, M48, M88, M96, M97, M109, M115, M116, M120,M134, M136, M142, M143, MA12, MA24, MA47, MA80, MA101, MA109, MA123,MA129, MA131, N32, N40, N47, N55, N73

Secondary Payment Remarks: M32, M43, M56, MA04, MA07, MA08, MA11, MA14,MA16, MA17, MA18, MA19, MA64, MA68, MA73, MA83, MA85, MA86, MA87, MA88,MA89, MA90, MA92, MA99, MA118, N4, N5, N6, N8, N9, N12, N23, N36, N48,N82,N89

Separate Payment Remarks: M2, M14, M15, M80, M86, M109, M121, M144, MA15, N15,N19, N20, N44, N61, N62, N63

Miscellaneous Remarks: M16, M70, M85, M87, M109, M114, M117, M118, M137, M144,MA22, MA23, MA26, MA45, MA67, MA74, MA79, MA93, MA103, MA106, MA117,MA118, MA19, MA124, MA125, MA132, MA133, N2, N7, N10, N13, N14, N16, N17,N18, N21, N22, N25, N35, N41, N44, N59,N74

Remark Codes

Code DescriptionValue

M1 X-ray not taken within the past 12 months or near enough to the start of treatment.M2 Not paid separately when the patient is an inpatient.M3 Equipment is the same or similar to equipment already being used.M4 This is the last monthly installment payment for this durable medical equipment.M5 Monthly rental payments can continue until the earlier of the 15th month from the

first rental month, or the month when the equipment is no longer needed.M6 You must furnish and service this item for as long as the patient continues to need

it. We can pay for maintenance and/or servicing for every 6 month period after theend of the 15th paid rental month or the end of the warranty period.

M7 No rental payments after the item is purchased, or after the total of issued rental payments equals the purchase price.

M8 We do not accept blood gas tests results when the test was conducted by a medicalsupplier or taken while the patient is on oxygen.

M9 This is the tenth rental month. You must offer the patient the choice of changingthe rental to a purchase agreement.

4

M10 Equipment purchases are limited to the first or the tenth month of medical necessity.

M11 DME, orthotics and prosthetics must be billed to the DME carrier who services thepatient's zip code.

M12 Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim.

M13 No more than one initial visit may be covered per specialty per medical group. Visit may be rebilled with an established visit code.

M14 No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.

M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

M16 See the letter or bulletin of (date) for further information. [Note: Payer must supplythe date of the letter/bulletin.]

M17 Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient.In the future, you will be liable for charges for the same service(s) under the sameor similar conditions.

M18 Certain services may be approved for home use. Neither a hospital nor a SNF isconsidered to be a patient's home.

M19 Oxygen certification/ recertification (HCFA-484) is incomplete or is required.M20 HCPCS needed.M21 Claim for services/items provided in a home must indicate the place of residence.M22 Claim lacks the number of miles traveled.M23 Invoice needed for the cost of the material or contrast agent.M24 Claim must indicate the number of doses per vial.M25 Payment has been (denied for the/made only for a less extensive) service because

the information furnished does not substantiate the need for the (more extensive)service. If you believe the service should have been fully covered as billed, or ifyou did not know and could not reasonably have been expected to know that wewould not pay for this (more extensive) service, or if you notified the patient inwriting in advance that we would not pay for this (more extensive) service andhe/she agreed in writing to pay, ask us to review your claim within six months ofreceiving this notice. If you do not request a review, we will, upon applicationfrom the patient, reimburse him/her for the amount you have collected fromhim/her (for the/in excess of any deductible and coinsurance amounts applicableto the less extensive) service. We will recover the reimbursement from you as anoverpayment.

M26 Payment has been (denied for the/made only for a less extensive) service becausethe information furnished does not substantiate the need for the (more extensive)service. If you have collected (any amount from the patient/any amount thatexceeds the limiting charge for the less extensive service), the law requires you torefund that amount to the patient within 30 days of receiving this notice.

The law permits exceptions to the refund requirement in two cases:

5

o If you did not know, and could not have reasonably been expected to know,that we would not pay for this service: or

o If you notified the patient in writing before providing the service that youbelieved that we were likely to deny the service, and the patient signed a statement agreeingto pay for the service.

If you come within either exception, or if you believe the carrier was wrong in itsdetermination that we do not pay for this service, you should request review of thisdetermination within 30 days of receiving this notice. Your request for reviewshould include any additional information necessary to support your position.

If you request review within the 30-day period, you may delay refunding theamount to the patient until you receive the results of the review. If the reviewdecisions favorable to you, you do not need to make any refund. If, however, thereview is unfavorable, the law specifies that you must make the refund within 15days of receiving the unfavorable review decision.

The law also permits you to request review at any time within six months ofreceiving this notice. A review requested after the 30-day period does not permityou to delay making the refund. Regardless of when a review is requested, thepatient will be notified that you have requested one, and will receive a copy of thedetermination.

The patient has received a separate notice of this denial decision. The noticeadvises that he/she may be entitled to a refund of any amounts paid, if you shouldhave known that we would not pay and did not tell him/her. It also instructs thepatient to contact your office if he/she does not hear anything about a refundwithin 30 days.

The requirements for refund are in §1842(l) of the Social Security Act and42CFR411.408. The section specifies that physicians who knowingly andwillfully fail to make appropriate refunds may be subject to civil monetarypenalties and/or exclusion from the program.

Contact this office if you have any questions about this notice.

M27 The patient has been relieved of liability of payment of these items and servicesunder the limitation of liability provision of the law. You, the provider, areultimately liable for the patient's waived charges, including any charges forcoinsurance, since the items or services were not reasonable and necessary orconstituted custodial care, and you knew or could reasonably have been expectedto know, that they were not covered.

You may appeal this determination provided that the patient does not exercisehis/her appeal rights. If the beneficiary appeals the initial determination, you areautomatically made a party to the appeals determination. If, however, the patientor his/her representative has stated in writing that he/she does not intend to request

6

a reconsideration, or the patient's liability was entirely waived in the initialdetermination, you may initiate an appeal.

You may ask for a reconsideration for hospital insurance (or a review for medicalinsurance) regarding both the coverage determination and the issue of whether youexercised due care. The request for reconsideration must be filed within 60 days(or 6 months for a medical insurance review) from the date of this notice. Youmay make the request through any Social Security office or through this office.

M28 This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available.

M29 Claim lacks the operative report.M30 Claim lacks the pathology report.M31 Claim lacks the radiology report.M3 This is a conditional payment made pending a decision on this service by the

patient's primary payer. This payment may be subject to refund upon your receiptof any additional payment for this service from another payer. You must contactthis office immediately upon receipt of an additional payment for this service.

M33 Claim lacks the UPIN of the ordering/referring or performing physician or practitioner, or the UPIN is invalid. (Substitute NPI for UPIN when effective)

M34 Claim lacks the CLIA certification number.

(Note: M34 duplicates remark code message MA120. Message M34 isinactive effective with implementation of version 4010 of the X12 835.M34may not be used after that date.)

M35 Claim lacks pre-operative photos or visual field results.M36 This is the 11th rental month. We cannot pay for this until you indicate that the

patient has been given the option of changing the rental to a purchase.M37 Service not covered when the patient is under age 35.M38 The patient is liable for the charges for this service as you informed the patient in

writing before the service was furnished that we would not pay for it, and the patient agreed to pay.

M39 The patient is not liable for payment for this service as the advance notice of noncoverage you provided the patient did not comply with program requirements.

M40 Claim must be assigned and must be filed by the practitioner's employer.M41 We do not pay for this as the patient has no legal obligation to pay for this.M42 The medical necessity form must be personally signed by the attending physician.M43 Payment for this service previously issued to you or another provider by another

carrier/intermediary.M44 Incomplete/invalid condition code.M45 Incomplete/invalid occurrence codes and dates.M46 Incomplete/invalid occurrence span code and dates.M47 Incomplete/invalid internal or document control number.M48 Payment for services furnished to hospital inpatients (other than professional

services of physicians )can only be made to the hospital. You must request payment from the hospital rather than the patient for this service.

M49 Incomplete/invalid value code(s) and/or amount(s).M50 Incomplete/invalid revenue code(s).

7

M51 Incomplete/invalid, procedure code(s) and/or rates, including “not otherwise classified” or “unlisted” procedure codes submitted without a narrative description or the description is insufficient.(Add to message by Medicare carriers only: “Refer to the HCPCS Directory. Ifan appropriate procedure code(s) does not exist, refer to Item 19 on the HCFA-1500 instructions.”)

M52 Incomplete/invalid “from” date(s) of service.M53 Did not complete or enter the appropriate number (one or more) of days or

units(s) of service.M54 Did not complete or enter the correct total charges for services rendered.M55 We do not pay for self-administered anti-emetic drugs that are not administered

with a covered oral anti-cancer drug.M56 Incomplete/invalid payer identification.M57 Incomplete/invalid provider number. (Substitute NPI for provider number when

effective.)M58 Resubmit the claim with the missing/correct information so that it may be

processed.M59 Incomplete/invalid “to” date(s) of service.M60 Rejected without appeal rights due to invalid CMN form or format. Resubmit

with completed, OMB-approved form or in an approved format.M61 We cannot pay for this as the approval period for the FDA clinical trial has

expired.M62 Incomplete/invalid treatment authorization code.M63 We do not pay for more than one of these on the same day.M64 Incomplete/invalid other diagnosis code.M65 One interpreting physician charge can be submitted per claim when a purchased

diagnostic test is indicated. Submit a separate claim for each interpreting physician.M66 Our records indicate that you billed diagnostic tests subject to price limitations

and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. Submit the technical and

professional components of this service as separate line items.M67 Incomplete/invalid other procedure code(s) and/or date(s).M68 Incomplete/invalid attending or referring physician identification.M69 Paid at the regular rate as you did not submit documentation to justify modifier 22.M70 NDC code submitted for this service was translated to a HCPCS code for

processing, but continue to submit the NDC on future claims for this item.M71 Total payment reduced due to overlap of tests billed.M72 Did not enter full 8-digit date (MM/DD/CCYY).

(Note: M72 duplicates remark code message MA52. Message M72 is inactiveeffective with implementation of version 4010 of the X12 835. M72 may not beused after that date.)

M73 The HPSA bonus can only be paid on the professional component of this service.Rebill as separate professional and technical components. Use the HPSA modifier on the professional component only.

8

M74 This service does not qualify for a HPSA bonus payment.M75 Allowed amount adjusted. Multiple automated multichannel tests performed on

the same day combined for payment.M76 Incomplete/invalid patient's diagnosis(es) and condition(s).M77 Incomplete/invalid place of service(s).M78 Did not complete or enter accurately an appropriate HCPCS modifier(s).M79 Did not complete or enter the appropriate charge for each listed service.M80 We cannot pay for this when performed during the same session as a previously

processed service for the patient.M81 Patient’s diagnosis code(s) is truncated, incorrect or missing; you are required to

code to the highest level of specificity.M82 Service is not covered when patient is under age 50.M83 Service is not covered unless the patient is classified as at high risk.M84 Old and new HCPCS cannot be billed for the same date of service.M85 Subjected to review of physician evaluation and management services.M86 Service denied because payment already made for similar procedure within set

time frame.M87 Claim/service(s) subjected to CFO-CAP prepayment review.M88 We cannot pay for laboratory tests unless billed by the laboratory that did the

work.M89 Not covered more than once under age 40.M90 Not covered more than once in a 12 month period.M91 Lab procedures with different CLIA certification numbers must be billed on

separate claims.M92 Services subjected to review under the Home Health Medical Review Initiative.M93 Information supplied supports a break in therapy. A new capped rental period

began with delivery of this equipment.M94 Information supplied does not support a break in therapy. A new capped rental

period will not begin.M95 Services subjected to Home Health Initiative medical review/cost report audit.M96 The technical component of a service furnished to an inpatient may only be billed

by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only.

M97 Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.

M98 Begin to report the Universal Product Number on claims for items of this type. Wewill soon begin to deny payment for items of this type if billed without the correctUPN.

M99 Incomplete/invalid/missing Universal Product Number.M100 We do not pay for an oral anti-emetic drug that is not administered for use

immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.

M101 Begin to report a G1-G5 modifier with this HCPCS. We will soon begin to denypayment for this service if billed without a G1-G5 modifier.

M102 Service not performed on equipment approved by the FDA for this purpose.

9

M103 Information supplied supports a break in therapy. However, the medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment.

M104 Information supplied supports a break in therapy. A new capped rental period willbegin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service.

M105 Information supplied does not support a break in therapy. The medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin.

M106 Information supplied does not support a break in therapy. A new capped rental period will not begin. This is the maximum approved under the fee schedule for this item or service.

M107 Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded36.5%.

M108 Must report the PIN of the physician who interpreted the diagnostic test. (Substitute NPI for PIN when effective.)

M109 We have provided you with a bundled payment for a teleconsultation. You mustsend 25 percent of the teleconsultation payment to the referring practitioner.

M110 Missing/invalid provider number for the provider from whom you purchased interpretation services.(Substitute NPI for provider number when effective.)

M111 We do not pay for chiropractic manipulative treatment when the patient refuses tohave an x-ray taken.

M112 The approved amount is based on the maximum allowance for this item under theDMEPOS Competitive Bidding Demonstration.

M113 Our records indicate that this patient began using this service(s) prior to the current round of the DMEPOS Competitive Bidding Demonstration. Therefore, the approved amount is based on the allowance in effect prior to this round of bidding for this item.

M114 This service was processed in accordance with rules and guidelines under the Competitive Bidding Demonstration Project. If you would like more informationregarding this project, you may phone 1-888-289-0710.

M115 This item is denied when provided to this patient by a nondemonstration supplier.M116 Even though this service is being paid in accordance with the rules and guidelines

under the Competitive Bidding Demonstration, future claims may be denied whenthis item is provided this patient by a nondemonstration supplier. If you would like more information regarding this project, you may phone 1-888-289-0710.

M117 Not covered unless supplier files an electronic media claim (EMC).M118 Letter to follow containing further information.M119 National Drug Code (NDC) needed.M120 Lacks UPIN of the substituting physician who furnished the service(s) under a

reciprocal billing or locum tenens arrangement. (Substitute NPI for UPIN when effective.)

M121 We pay for this service only when performed with a covered cryosurgical ablation.

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M122 Level of subluxation is missing or inadequate.M123 Failed to submit the name, strength, or dosage of the drug furnished.M124 Information to indicate if the patient owns the equipment that requires the part or

supply was missing.M125 Information about the period of time for which this will be needed was missing.M126 The individual lab codes included in the test were not submitted.M127 The patient’s medical record for this service was not submitted with the claim as

required.M128 The date of the patient’s most recent physician visit must be submitted.M129 Indicator lacking that “X-ray is available for review.”M130 Invoice or statement certifying the actual cost of the lens, less discounts, or the

type of intraocular lens used was missing.M131 Completed physician financial relationship form not on file.M132 Completed pacemaker registration form required.M133 Claim did not identify who performed the purchased diagnostic test or the amount

you were charged for the test.M134 Performed by a facility/supplier in which the ordering/referring physician has a

financial interest.M135 Claim lacked indication that the plan of treatment is on file.M136 Claim lacked indication that the service was supervised or evaluated by a

physician.M137 Part B coinsurance under a demonstration project.M138 Patient identified as a demonstration participant but the patient was not enrolled

in the demonstration at the time services were rendered. Coverage is limited to demonstration participants.

M139 Denied services exceed the coverage limit for the demonstration.M140 Service not covered until after the patient’s 50th birthday, i.e., no coverage prior

to the day after the 50th birthday.M141 Missing/incomplete/invalid physician certified plan of care.M142 Missing/incomplete/invalid American Diabetes Association Certificate of

Recognition to establish qualification.M143 We have no record that you are licensed to dispensed drugs in the State where

located.M144 Pre-/post-operative care payment is included in the allowance for the

surgery/procedure.

MA01 (Initial Part B determination, Medicare carrier or intermediary)--If you do notagree with what we approved for these services, you may appeal our decision. Tomake sure that we are fair to you, we require another individual that did notprocess your initial claim to conduct the review. However, in order to be eligiblefor a review, you must write to us within 6 months of the date of this notice, unlessyou have a good reason for being late.

(Note: An intermediary must add: An institutional provider, e.g., hospital, SNF,HHA may appeal only if the claim involves a medical necessity denial, a SNF

11

recertified bed denial, or a home health denial because the patient was nothomebound or was not in need of intermittent skilled nursing services, and eitherthe patient or the provider is liable under §1879 of the Social Security Act, and thepatient chooses not to appeal.)

(Note: Carriers who issue telephone review decisions should add: If you meet the criteria for a telephone review, you should phone this office if you wish to request a telephone review.)

MA02 (Initial Medicare Part A determination)--If you do not agree with thisdetermination, you have the right to appeal. You must file a written request for areconsideration within 60 days of receipt of this notification. Decisions made bya PRO must be appealed to that PRO. (An institutional provider, e.g., hospital,SNF, HHA, may appeal only if the claim involves a medical necessity denial, aSNF noncertified bed denial, or a home health denial because the patient was nothomebound or was not in need of intermittent skilled nursing services, and eitherthe patient or the provider is liable under §1879 of the Social Security Act, andthe patient chooses not to appeal.)

MA03 (Medicare Hearing)--If you do not agree with the approved amounts and $100 ormore is in dispute (less deductible and coinsurance), you may ask for a hearing.You must request a hearing within 6 months of the date of this notice. To meet the$100, you may combine amounts on other claims that have been denied. Thisincludes reopened reviews if you received a revised decision. You must appealeach claim on time. At the hearing, you may present any new evidence whichcould affect our decision.

(Note: An Intermediary must add: An institutional provider, e.g., hospital, SNF,home health care, may appeal only if the claim involves a medical necessitydenial, a SNF noncertified bed denial, or a home health denial because the patientwas not homebound or was not in need of intermittent skilled nursing services, andeither the patient or the provider is liable under §1879 of the Social Security Act,and the patient chooses not to appeal.)

MA04 Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

MA05 Incorrect admission date, patient status or type of bill entry on claim.

(Note: MA05 duplicates information in remark codes MA30, MA40 and MA43.Message MA05 is inactive effective with implementation of version 4010 of theX12 835. MA05 may not be used after that date.)

MA06 Incorrect/incomplete/missing beginning and/or ending date(s) on claim.MA07 The claim information has also been forwarded to Medicaid for review.MA08 You should also submit this claim to the patient's other insurer for potential

payment of supplemental benefits. We did not forward the claim information asthe supplemental coverage is not with a Medigap plan, or you do not participatein Medicare.

12

MA09 Claim submitted as unassigned but processed as assigned. You agreed to accept assignment for all claims.

MA10 The patient's payment was in excess of the amount owed. You must refund the overpayment to the patient.

MA11 Payment is being issued on a conditional basis. If no-fault insurance, liabilityinsurance, workers' compensation, Department of Veterans Affairs, or a group health plan for employees and dependents also covers this claim, a refund may bedue us. Contact us if the patient is covered by any of these sources.

MA12 You have not established that you have the right under the law to bill for servicesfurnished by the person(s) that furnished this (these) service(s).

MA13 You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.

MA14 Patient is a member of an employer-sponsored prepaid health plan. Services fromoutside that health plan are not covered. However, as you were not previously notified of this, we are paying this time. In the future, we will not pay you for non-plan services.

MA15 Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported.

MA16 The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.

MA17 We are the primary payer and have paid at the primary rate. You must contact thepatient's other insurer to refund any excess it may have paid due to its erroneous primary payment.

MA18 The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them.

MA19 Information was not sent to the Medigap insurer due to incorrect/invalidinformation you submitted concerning that insurer. Verify yourinformation andsubmit your secondary claim directly to that insurer.

MA20 SNF stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.

MA21 SSA records indicate mismatch with name and sex.MA22 Payment of less than $1.00 suppressed.MA23 Demand bill approved as result of medical review.MA24 Christian Science Sanitorium/SNF bill in the same benefit period.MA25 A patient may not elect to change a hospice provider more than once in a benefit

period.MA26 Our records indicate that you were previously informed of this rule.MA27 Incorrect entitlement number or name shown on the claim. Use the entitlement

number or name shown on this notice for future claims for this patient.MA28 Receipt of this notice by a physician or supplier who did not accept assignment is

for information only and does not make the physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice.

13

MA29 Incomplete/invalid provider name, city, State, and zip code.MA30 Incomplete/invalid type of bill.MA31 Incomplete/invalid beginning and ending dates of the period billed.MA32 Incomplete/invalid number of covered days during the billing period.MA33 Incomplete/invalid number of noncovered days during the billing period.MA34 Incomplete/invalid number of coinsurance days during the billing period.MA35 Incomplete/invalid number of lifetime reserve days.MA36 Incomplete/invalid patient's name.MA37 Incomplete/invalid patient's address.

(Note: When used, a payer must verify that an address, with city, State, and zipcode, and a phone number are present.)

MA38 Incomplete/invalid patient's birthdate.MA39 Incomplete/invalid patient's sex.MA40 Incomplete/invalid admission date.MA41 Incomplete/invalid type of admission.MA42 Incomplete/invalid source of admission.MA43 Incomplete/invalid patient status.MA44 No appeal rights. Adjudicative decision based on law.MA45 As previously advised, a portion or all of your payment is being held in a special

account.MA46 The new information was considered, however, additional payment cannot be

issued. Review the information listed for the explanation.MA47 Our records show you have opted out of Medicare, agreeing with the patient not

to bill Medicare for services/tests/supplies furnished. As result, we cannot pay thisclaim. The patient is responsible for payment

MA48 Incomplete/invalid name and/or address of responsible party or primary payer .MA49 Incomplete/invalid six-digit provider number of home health agency or hospice

for physician(s) performing care plan oversight services.MA50 Incomplete/invalid investigational device exemption number for FDA-approved

clinical trial services.MA51 Incomplete/invalid CLIA certification number for laboratory services billed by

physician office laboratory.MA52 Did not enter full 8-digit date (MM/DD/CCYY for paper form or CCYY/MM/DD

for electronic format).MA53 Inconsistent demonstration project information. Correct and resubmit with

information on no more than one demonstration project.MA54 Physician certification or election consent for hospice care not received timely.MA55 Not covered as patient received medical health care services, automatically

revoking his/her election to receive religious non-medical health care services.MA56 Our records show you have opted out of Medicare, agreeing with the patient not

to bill Medicare for services/tests/supplies furnished. As result, we cannot pay thisclaim. The patient is responsible for payment, but under Federal law, you cannotcharge the patient more than the limiting charge amount.

MA57 Patient submitted written request to revoke his/her election for religious non-medical health care services.

MA58 Incomplete release of information indicator.

14

MA59 The patient overpaid you for these services. You must issue the patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice.

MA60 Incomplete/invalid patient's relationship to insured.MA61 Did not complete or enter correctly the patient's social security number or health

insurance claim number.MA62 Telephone review decisionMA63 Incomplete/invalid principal diagnosis code.MA64 Our records indicate that we should be the third payer for this claim. We cannot

process this claim until we have received payment information from the primaryand secondary payers.

MA65 Incomplete/invalid admitting diagnosis.MA66 Incomplete/invalid principal procedure code and/or date.MA67 Correction to a prior claim.MA68 We did not crossover this claim because the secondary insurance information on

the claim was incomplete. Supply complete information or use the PLANID of theinsurer to assure correct and timely routing of the claim.

MA69 Incomplete/invalid remarks.MA70 Incomplete provider representative signature.MA71 Incomplete/invalid provider representative signature date.MA72 The patient overpaid you for these assigned services. You must issue the patient

a refund within 30 days for the difference between his/her payment to you and thetotal of the amount shown as patient responsibility and as paid to the patient on thisnotice.

MA73 Informational remittance associated with a Medicare demonstration. No paymentissued under fee-for-service Medicare as patient has elected managed care.

MA74 This payment replaces an earlier payment for this claim that was either lost, damaged or returned.

MA75 Our records indicate neither a patient's or authorized representative's signature was submitted on the claim. Since this information is not on file, resubmit.

MA76 Incomplete/invalid provider number of HHA or hospice when physician is performing care plan oversight services.

MA77 The patient overpaid you. You must issue the patient a refund within 30 days forthe difference between the patient’s payment less the total of our and other payerpayments and the amount shown as patient responsibility on this notice.

MA78 The patient overpaid you. You must issue the patient a refund within 30 days forthe difference between our allowed amount total and the amount paid by the patient.

MA79 Billed in excess of interim rate.MA80 Informational notice. No payment issued for this claim with this notice. Payment

issued to the hospital by its intermediary for all services for this encounter undera demonstration project.

MA81 Our records indicate neither a physician or supplier signature is on the claim or onfile.

MA82 Did not complete or enter the correct physician/supplier's billing number/NPI and/or billing name, address, city, State, zip code, and phone number.

15

MA83 Did not indicate whether we are the primary or secondary payer. Refer to Item 11in the HCFA-1500 instructions for assistance.

MA84 Patient identified as participating in the National Emphysema Treatment Trial butour records indicate that this patient is either not a participant, or has not yet beenapproved for this phase of the study. Contact Johns Hopkins University, the studycoordinator, to resolve if there was a discrepancy.

MA85 Our records indicate that a primary payer exists (other than ourselves); however,you did not complete or enter accurately the insurance plan/group/program nameor identification number. Enter the PlanID when effective.

MA86 Our records indicate that there is insurance primary to ours; however, you either did not complete or enter accurately the group or policy number of the insured.

MA87 Our records indicate that a primary payer exists (other than ourselves); however,you did not complete or enter accurately the correct insured's name.

MA88 Our records indicate that a primary payer exists (other than ourselves); however,you did not complete or enter accurately the insured's address and/or telephone number.

MA89 Our records indicate that a primary payer exists (other than ourselves); however,you did not complete or enter the appropriate patient's relationship to the insured.

MA90 Our records indicate that there is insurance primary to ours; however, you either did not complete or enter accurately the employment status code of the primary insured.

MA91 This determination is the result of the appeal you filed.MA92 Our records indicate that there is insurance primary to ours; however, you did not

complete or enter accurately the required information.

(NOTE: Carriers must also add: Refer to the HCFA-1500 instructions on how tocomplete MSP information.)

MA93 Non-PIP claim.MA94 Did not enter the statement “Attending physician not hospice employee”on the

claim to certify that the rendering physician is not an employee of the hospice. Refer to item 19 on the HCFA-1500.

MA95 A “not otherwise classified” or “unlisted” procedure code(s) was billed, but a narrative description of the procedure was not entered on the claim. Refer to item19 on the HCFA-1500.

MA96 Claim rejected. Coded as a Medicare Managed Care Demonstration but patient isnot enrolled in a Medicare managed care plan.

MA97 Claim rejected. Does not contain the Medicare Managed Care Demonstrationcontract number, however, the beneficiary is enrolled in a Medicare managed careplan.

MA98 Claim rejected. Does not contain the correct Medicare Managed CareDemonstration contract number for this beneficiary.

MA99 Our records indicate that a Medigap policy exists; however, you did not completeor enter accurately any of the required information. Refer to the HCFA-1500 instructions on how to complete a mandated Medigap transfer.

MA100 Did not complete or enter accurately the date of current illness, injury or pregnancy.

16

MA101 A SNF is responsible for payment of outside providers who furnish theseservices/supplies to residents.

MA102 Did not complete or enter accurately the referring/ordering/supervising physician's/physician’s assistant’s, nurse practitioner’s, or clinical nurse specialist’s name and/or UPIN. (Substitute “NPI” for “UPIN” when effective.)

MA103 Hemophilia add onMA104 Did not complete or enter accurately the date the patient was last seen and/or the

UPIN of the attending physician. (Substitute “NPI” for “UPIN” wheneffective.)

MA105 Missing/invalid provider number for this place of service. Place of service code shown as 21, 22, or 23 (hospital). (Substitute “NPI” for provider number wheneffective.)

MA106 PIP claimMA107 Paper claim contains more than three separate data items in field 19.MA108 Paper claim contains more than one data item in field 23.MA109 Claim processed in accordance with ambulatory surgical guidelines.MA110 Our records indicate that you billed diagnostic test(s) subject to price limitations;

however, you did not indicate whether the test(s) were performed by an outside entity or if no purchased tests are included on the claim.

MA111 Our records indicate that you billed diagnostic test(s) subject to price limitations and indicated that the test(s) were performed by an outside entity; however, you did not indicate the purchase price of the test(s) and/or the performing laboratory'sname and address.

MA112 Our records indicate that the performing physician/supplier/practitioner is a member of a group practice; however, you did not complete or enter accurately their carrier assigned individual and group PINs. (Substitute “NPI” for “PIN”when effective.)

MA113 Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN.

MA114 Did not complete or enter accurately the name and address, the carrier assignedPIN, or the regional office assigned OSCAR number of the entity where serviceswere furnished. (Substitute“NPI” for “PIN” when effective.)

MA115 Our records indicate that you billed one or more services in a Health professionalshortage area (HPSA); however, you did not enter the physical location (name andaddress, or PIN) where the service(s) were rendered. (Substitute “NPI” for“PIN” when effective.)

MA116 Did not complete the statement "Homebound" on the claim to validate whether laboratory services were performed at home or in an institution.

MA117 This claim has been assessed a $1 user fee.MA118 Coinsurance and/or deductible amounts apply to a claim for services or supplies

furnished to a Medicare-eligible veteran through a facility of the Department ofVeterans Affairs. No Medicare payment issued.

MA119 Provider level adjustment for late claim filing applies to this claim.

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MA120 Did not complete or enter accurately the CLIA number.MA121 Did not complete or enter accurately the date the x-ray was performed.MA122 Did not complete or enter accurately the initial date "actual" treatment occurred.MA123 Your center was not selected to participate in this study, therefore, we cannot pay

for these services.MA124 Processed for IME only.MA125 Per legislation governing this program, payment constitutes payment in full.MA126-127 Reserved for future useMA128 Did not complete or enter accurately the six digit FDA approved, identification

number.MA129 This provider was not certified for this procedure on this date of service. Effective

1/1/98, we will begin to deny payment for such procedures. Contact to correct orobtain CLIA certification. (Claim processor must provide the name and phonenumber of the State agency to be contacted.)

MA130 Your claim contains incomplete and/or invalid information, and no appeal rightsare afforded because the claim is unprocessable. Submit a new claim with thecomplete/correct information.

MA131 Physician already paid for services in conjunction with this demonstration claim.You must have the physician withdraw that claim and refund the payment beforewe can process your claim.

MA132 Adjustment to the pre-demonstration rate.MA133 Claim overlaps inpatient stay. Rebill only those services rendered outside the

inpatient stay.MA134 Missing/incomplete/invalid provider number of the facility where the patient

resides.

N1 You may appeal this decision in writing within the required time limits followingreceipt of this notice.

N2 This allowance has been made in accordance with the most appropriate course oftreatment provision of the plan.

N3 Required/consent form incomplete, incorrect, or not on file.N4 Prior insurance carrier EOB received was insufficient.N5 EOB received from previous payer. Claim not on file.N6 Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the

amount Medicare would have allowed if the patient were enrolled in Medicare Part A.

N7 Processing of this claim/service has included consideration under major medicalprovisions.

N8 Crossover claim denied by previous payer and complete claim data not forwarded.Resubmit this claim to this payer to provide adequate data for adjudication.

N9 Adjustment represents the estimated amount the primary payer may have paid.N10 Claim/service adjusted because of the finding of a review organization/professional

consult/manual adjudication.N11 Denial reversed because of medical review.

18

N12 Policy provides coverage supplemental to Medicare. As member does not appearto be enrolled in Medicare Part B, the member is responsible for payment of the portion of the charge that would have been covered by Medicare.

N13 Payment based on professional/technical component modifier(s).N14 Payment based on a contractual amount or agreement, fee schedule, or maximum

allowable amount.N15 Services for a newborn must be billed separately.N16 Family/member out-of-pocket maximum has been met. Payment based on a

higher percentage.N17 Per admission deductible.N18 Payment based on the Medicare allowed amount.N19 Procedure code incidental to primary procedure.N20 Service not payable with other service rendered on the same date.N21 Range of dates separated onto single lines.N22 This procedure was added because it more accurately describes the services

rendered.N23 Patient liability may be affected due to coordination of benefits with primary

carrier and/or maximum benefit provisions.N24 Electronic funds transfer (EFT) banking information incomplete/invalid.N25 This company has been contracted by your benefit plan to provide administrative

claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan.

N26 Itemized bill required for claim adjudication.N27 Treatment number not indicated on claim.N28 Consent form requirements not fulfilled.N29 Required documentation/orders/notes/summary/report/invoice needed to

adjudicate.N30 Recipient ineligible for this service.N31 Prescribing/referring/attending practitioner license number is

absent/incorrect/incomplete.N32 Provider performing service must submit claim.N33 No record of health check prior to initiation of treatment.N34 Incorrect claim form for this service.N35 Program integrity/utilization review decision.N36 Claim must meet primary payer’s processing requirements before we can consider

payment.N37 Tooth number/letter required.N38 Place of service missing.N39 Procedure code is not compatible with tooth number/letter.N40 Procedure requires x-ray.N41 Authorization request denied. (Note: N41 duplicates reason code message 39.

Message N41 is inactive effective with implementation of version 4010 of the X12835. N41 may not be used after that date.)

N42 No record of mental health assessment.N43 Bed hold or leave days exceeded.

19

N44 Payor’s share of regulatory surcharges, assessments, allowances or health care-related taxes paid directly to the regulatory authority. (Note: N44 duplicatesremark code message 137. Message N44 is inactive effective with implementationof version 4010 of the X12 835. N44 may not be used after that date.)

N45 Payment based on authorized amount.N46 Missing/incomplete/invalid admission hour.N47 Claim conflicts with another inpatient stay.N48 Claim information does not agree with information received from other insurance

carrier.N49 Court ordered coverage information needs validation.N50 Discharge information missing/incomplete/incorrect/invalid.N51 Electronic interchange agreement not on file for provider/submitter.

N52 Patient not enrolled in the billing provider=s managed care plan on the date ofservice.

N53 Incomplete/invalid street, city, state and/or zip code for the point of pickup.N54 Claim information is inconsistent with pre-certified/authorized services.N55 Procedures for billing with group/referring/performing providers were not

followed.N56 Procedure code billed is not correct for the service billed.N57 Missing/incomplete/invalid prescribing/dispensed date.N58 Patient liability amount missing, invalid, or not on file.N59 Refer to your provider manual for additional program and provider information.N60 A valid NDC is required for payment of drug claims effective October 2002.N61 Rebill services on separate claims.N62 Inpatient admission spans multiple rate periods. Resubmit separate cla ims.N63 Rebill services on separate claim lines.N64 The “from” and “to” dates must be different.N65 Procedure code or procedure rate count cannot be determined, or was not on

file, for the date of service/provider. Contact the Health Plan prior to refilingthe claim.

N66 Claim lacks necessary documentation.N67 Professional provider services not paid separately. Included in facility payment

under a demonstration project. Apply to that facility for payment, or resubmityour claim if: the facility notifies you the patient was excluded from thisdemonstration; or if you furnished these services in another location on the dateof the patient’s admission or discharge from a demonstration hospital. Ifservices were furnished in a facility not involved in the demonstration on thesame date the patient was discharged from or admitted to a demonstrationfacility, you must report the provider ID number for the non-demonstrationfacility on the new claim.

N68 Prior payment being cancelled as we were subsequently notified this patientwas covered by a demonstration project in this site of service. Professionalservices were included in the payment made to the facility. You must contactthe facility for your payment. Prior payment made to you by the patient oranother insurer for this claim must be refunded to the payer within 30 days.

N69 PPS code changed by claims processing system. Insufficient visits or therapies.N70 Home health consolidated billing and payment applies. Ancillary

providers/suppliers must contact the HHA for reimbursement.

20

N71 Your unassigned claim for a drug or biological was processed as an assignedclaim. The law requires you must take assignments on all claims for drugs andbiologicals.

N72 PPS code changed by medical reviewers. Not supported by clinical records.N73 A SNF is responsible for payment of outside providers who furnish these

services/supplies to residents.N74 Resubmit with multiple claims, each claim covering services provided in only

one calendar monthN75 Missing or invalid tooth surface informationN76 Missing or invalid number of riders (for ambulance services)N77 Missing or invalid designated provider numberN78 The necessary components of the child and teen checkup (EPSDT) were not

completed.N79 Service billed is not compatible with patient location informationN80 Missing or invalid prenatal screening informationN81 Procedure billed is not compatible with tooth surface codeN82 Provider must accept insurance payment as payment in full when a third party

payer contract specifies full reimbursement.N83 No appeal rights. Adjudicative decision based on the provisions of a demonstration

project.N84 Further installment payments forthcoming.N85 Final installment payment.N86 A failed trial of pelvic muscle exercise training is required in order for biofeedback

training for the treatment of urinary incontinence to be covered.N87 Home use of biofeedback therapy is not covered.N88 This payment is being made conditionally. An HHA episode of care notice has

been filed for this patient. When a patient is treated under a HHA episode of care,consolidated billing requires that certain therapy services and supplies, such asthis, be included in the HHA’s payment. This payment will need to be recoupedfrom you if we establish that the patient is concurrently receiving treatment undera HHA episode of care.

N89 Payment information for this claim has been forwarded to more than one otherpayer, but format limitations permit only one of the secondary payers to beidentified in this remittance advice.

REQUESTS FOR ADDITIONAL CODES

HCFA has national responsibility for maintenance of the remittance advice remark codes.Requests for new or changed remark codes should be submitted to HCFA via theWashington Publishing Company webpage remark code request function. Requests forcodes must include the name, phone number, company name, and e-mail address of therequestor, the suggested wording for the new or revised message, and an explanation of howthe message will be used and why it is needed. A fax number or mail address is acceptablein the absence of an e-mail address. Requests may also be mailed to: Health Care FinancingAdministration, OIS/SSG/DHCISS, Mail Stop N2-14-26, 7500 Security Blvd., BaltimoreMD 21244-1850. HCFA expects to issue a response to most remark message requests within2 weeks of receipt.

Attachment 3

CARRIER NAMEADDRESS 1 MEDICAREADDRESS 2 REMITTANCECITY, STATE ZIP NOTICE(9099) 111-2222

PERF PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS PROV PD RC-AMT

NAME LLLLLLLLLLLL, FFFFFFFF HIC 123456789012 ACNT 12345678901234567890 ICN 123456789012345 ASG X MOA 11111 22222 33333 44444 55555

1234567890 MMDD MMDDYY 12 123 PPPPP aabbccdd 1234567.12 1234567.12 1234.12 12345.12 1234567.12 RRRRRR 12345.12 (PPPPP) RRRRRR 12345.121234567890 MMDD MMDDYY 12 123 PPPPP aabbccdd 1234567.12 1234567.12 1234.12 12345.12 1234567.12 RRRRRR 12345.12REM: RRRRR RRRRR RRRRR RRRRR RRRRR1234567890 MMDD MMDDYY 12 123 PPPPP aabbccdd 1234567.12 1234567.12 1234.12 12345.12 1234567.12 RRRRRR 12345.12PT RESP 12345.12 CLAIM TOTALS 1234567.12 1234567.12 1234.12 12345.12 1234567.12 1234567.12 NETADJS: PREV PD 1234567.12 PD TO BENE 1234567.12 INT 1234567.12 MSP 1234567.12 OTHER RRRRRR 1234567.12CLAIM INFORMATION FORWARDED TO : XXXXXXXXXXXXXXXXXXXXXXX RRRRRR 1234567.12

RRRRRR 1234567.12